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BACKGROUND: While there is extensive empirical support and clinical guidance for the treatment of mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) individually, less is known about treating the comorbid presentation of both conditions. OBJECTIVE: The purpose of this review article is to provide information on the mental health treatment needs of service members (SMs) engaged in traumatic brain injury (TBI) rehabilitation. It also aims to offer a framework for an integrated treatment approach to address the cognitive and psychological health needs of warfighters. METHODS: We review the prevalence and outcomes associated with comorbid TBI and PTSD and present relevant access to care considerations. Additionally, we identify an integrated approach to TBI treatment which takes psychological trauma into consideration. We introduce a trauma-informed care (TIC) model with specified diagnostic and treatment considerations for the service member and veteran (SM/V) communities. TIC is a strengths-based framework that raises the system-wide awareness of treatment facilities to the impact of psychological trauma on behavioral health. RESULTS: A comprehensive diagnostic approach is recommended with considerations for symptom etiology. Clinical considerations derived from available guidelines are identified to meet critical treatment needs for SM/Vs presenting for TBI treatment with a remote history of mTBI and psychological trauma or known PTSD. Clinical practice guidelines are used to inform an integrated TBI treatment model and maximize rehabilitation efforts for warfighters. CONCLUSION: Given the prevalence of comorbid TBI and PTSD among SM/Vs and its impact on outcomes, this review presents the integration of appropriate diagnostics and treatment practices, including the incorporation of clinical practice guidelines (CPGs) into TBI rehabilitation. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the trajectory of parent-rated post-concussive symptoms (PCS), attentional performance and participation within 6 months in children after mild traumatic brain injury (mTBI). For this prospective longitudinal study, we included data on 64 children after mTBI and 57 healthy control children (age 8–16 years). Parents rated PCS using the Post-Concussion Symptom Inventory (PCSI) immediately (T0), 1 week (T1), and 3–6 months after injury (T2). Attentional performance (alertness, selective and divided attention) was measured using the Test of Attentional Performance (TAP) at T1 and T2 and participation was measured using the Child and Adolescent Scale of Participation (CASP) at T2. Friedman tests showed different trajectories of PCS subscales over time: Compared to pre-injury level, the amount of somatic and cognitive PCS was still elevated at T1, while emotional PCS at T1 were already comparable to pre-injury level. The rating of sleep-related PCS at T2 was significantly elevated compared to the pre-injury rating. Quade ANCOVAs indicated group differences in PCS subscales between patients and controls at T1, but not at T2. Patients and controls showed a similar performance in tests of attention at T1 and T2, but parental rating of participation at school was significantly reduced. Although cognitive PCS and attention were not correlated, there were significantly negative Spearman correlations between participation at home and pre-injury and concurrent PCS at T2. Our data imply that sleep-related PCS are still elevated weeks after injury and are thus a target for interventions after mTBI. [ABSTRACT FROM AUTHOR]

Background: This exploratory study sought to describe parent–child interaction after a mild traumatic brain injury (mTBI) or mild limb injury (LI), and to examine the relationship between the quality of interactions and child/parent characteristics (e.g. developmental status, pre-injury behaviour, parental stress), post-concussive symptoms (PCS), and post-injury behaviour. Methods: Children aged 2–5 years and their parents were recruited from the emergency department (ED). Nine child–parent dyads (mTBI n = 6, LI n = 3) agreed to participate in the direct observation of parent–child interaction at 1 week post-injury. PCS were assessed during ED presentation, at 1 month, and 3 months post-injury, and post-injury behaviour was assessed at the 3-month follow-up. Results: Parent–child interaction was suboptimal for most of the dyads at 1 week following a mild traumatic injury in preschoolers. The quality of interaction was positively related to the child's developmental status, and negatively related to parental stress, acute PCS, and pre- and post-injury behaviour. Conclusions: Further research is needed to expound on parent–child interactions post-mTBI and to determine their predictive utility for parent-rated child outcomes. Both parent and child aspects of the interaction may provide useful information regarding potential avenues for clinical intervention post-injury. Preschool children are heavily reliant on their parents to report on their symptoms after a mild traumatic brain injury. Little is currently known regarding what may impact parental reports, and this study found that the quality of parent‐child interaction is linked with parents' ratings of child behaviour and post‐concussive symptoms. The quality of parent‐child interaction may provide important information when assessing recovery and possible avenues for intervention post‐injury. [ABSTRACT FROM AUTHOR]

Background: In the context of managing persistent post-concussive symptoms (PPCS), existing treatments like pharmacotherapy, cognitive behavioral therapy, and physical rehabilitation show only moderate effectiveness. The emergence of neuromodulation techniques in PPCS management has led to debates regarding optimal stimulation parameters and their overall efficacy. Methods: this scoping review involved a comprehensive search of PubMed and ScienceDirect databases, focusing on controlled studies examining the therapeutic potential of non-invasive brain stimulation (NIBS) techniques in adults with PPCS. Results: Among the 940 abstracts screened, only five studies, encompassing 103 patients (12 to 29 per study), met the inclusion criteria. These studies assessed the efficacy of transcranial direct current stimulation (tDCS), or repetitive transcranial magnetic stimulation (rTMS), applied to specific brain regions (i.e., the left dorsolateral pre-frontal cortex (DLPFC) or left motor cortex (M1)) for addressing cognitive and psychological symptoms, headaches, and general PPCSs. The results indicated improvements in cognitive functions with tDCS. In contrast, reductions in headache intensity and depression scores were observed with rTMS, while no significant findings were noted for general symptoms with rTMS. Conclusion: although these pilot studies suggest promise for rTMS and tDCS in PPCS management, further research with larger-scale investigations and standardized protocols is imperative to enhance treatment outcomes for PPCS patients. [ABSTRACT FROM AUTHOR]

Abstract Background Concussion may lead to persisting post-concussive symptoms affecting work ability and employment. This study examined the transitions between labour market states an individual can experience after the acute phase of concussion. The aim was to describe the incidence of favourable and adverse transitions between different labour market states (e.g., employment, sick leave) in relation to socioeconomic and health characteristics in individuals with concussion relative to matched controls. Methods This Danish nationwide register-based cohort study extracted 18–60-year-old individuals between 2003–2007 with concussion from the Danish National Patient Register (ICD-10 S06.0). Controls were matched on age, sex, and municipality. Patients and controls were followed for 5 years starting three months after injury. Exclusion criteria were neurological injuries and unavailability to the labour market in the inclusion period (2003–2007) and 5-years before injury (1998–2002). Labour market states were defined from transfer income data in the Danish Register for Evaluation of Marginalization. Incidence rates of transitions between these labour market states were analysed in multistate models. Transitions were bundled in favourable and adverse transitions between labour market states and the difference in incidence rates between individuals with concussion relative to matched controls were assessed with hazard ratios from Cox regression models. Results Persons with concussion (n = 15.580) had a lower incidence of favourable transitions (HR 0.88, CI 0.86–0.90) and a higher incidence of adverse transitions (HR 1.30, CI 1.27–1.35), relative to matched controls (n = 16.377). The effect of concussion differed depending on health and socioeconomic characteristics. Notably, individuals between 30–39 years (HR 0.83, CI 0.79–0.87), individuals with high-income (200.000–300.000 DKK) (HR 0.83, CI 0.80–0.87), and wage earners with management experience (HR 0.60, CI 0.44–0.81) had a markedly lower incidence of favourable transitions compared to controls. Additionally, individuals with high income also had a higher incidence of adverse transitions (HR 1.46, CI 1.34–1.58) compared to controls. Conclusions Concussion was associated with enhanced risk of adverse transitions between labour market states and lower occurrence of favourable transitions, indicating work disability, potentially due to persistent post-concussive symptoms. Some age groups, individuals with high income, and employees with management experience may be more affected.

The purpose of this study was to examine neurobehavioral symptom reporting in a large sample of military veterans (N = 12,144) who completed the Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and enrolled in the VA's Million Veteran Program (MVP). The CTBIE is a clinician-administered interview that assesses for historical, deployment-related traumatic brain injury (TBI) and evaluates symptoms using the Neurobehavioral Symptom Inventory (NSI). Clinicians completing the CTBIE made clinical determinations about participants' (1) TBI diagnostic status (i.e., CTBIE+ or CTBIE-) and (2) current symptom etiology (i.e., Symptom Resolution, TBI, Behavioral Health, Comorbid TBI + Behavioral Health [Comorbid], or Other). We evaluated the association of TBI diagnostic status and symptom etiology group with neurobehavioral symptoms. Results showed a significant association between TBI diagnostic status and all NSI variables, with CTBIE+ veterans endorsing greater symptoms than CTBIE- veterans. There was also a significant association between symptom etiology group and all NSI variables; specifically, the Comorbid and Behavioral Health groups generally endorsed significantly greater symptoms compared to the other groups. Follow-up analyses showed that relative to the Symptom Resolution group, the Comorbid and Behavioral Health groups had increased odds of severe/very severe cognitive and affective symptoms, whereas the TBI and Other groups did not. Finally, presence of psychiatric symptoms, pain, post-traumatic amnesia, loss of consciousness, and blast exposure significantly predicted Comorbid symptom etiology group membership. Findings from this large epidemiologic MVP study have relevant clinical implications and further highlight the importance of prioritizing integrated behavioral health interventions for this vulnerable population.

Background: Concussion may lead to persisting post-concussive symptoms affecting work ability and employment. This study examined the transitions between labour market states an individual can experience after the acute phase of concussion. The aim was to describe the incidence of favourable and adverse transitions between different labour market states (e.g., employment, sick leave) in relation to socioeconomic and health characteristics in individuals with concussion relative to matched controls. Methods: This Danish nationwide register-based cohort study extracted 18–60-year-old individuals between 2003–2007 with concussion from the Danish National Patient Register (ICD-10 S06.0). Controls were matched on age, sex, and municipality. Patients and controls were followed for 5 years starting three months after injury. Exclusion criteria were neurological injuries and unavailability to the labour market in the inclusion period (2003–2007) and 5-years before injury (1998–2002). Labour market states were defined from transfer income data in the Danish Register for Evaluation of Marginalization. Incidence rates of transitions between these labour market states were analysed in multistate models. Transitions were bundled in favourable and adverse transitions between labour market states and the difference in incidence rates between individuals with concussion relative to matched controls were assessed with hazard ratios from Cox regression models. Results: Persons with concussion (n = 15.580) had a lower incidence of favourable transitions (HR 0.88, CI 0.86–0.90) and a higher incidence of adverse transitions (HR 1.30, CI 1.27–1.35), relative to matched controls (n = 16.377). The effect of concussion differed depending on health and socioeconomic characteristics. Notably, individuals between 30–39 years (HR 0.83, CI 0.79–0.87), individuals with high-income (200.000–300.000 DKK) (HR 0.83, CI 0.80–0.87), and wage earners with management experience (HR 0.60, CI 0.44–0.81) had a markedly lower incidence of favourable transitions compared to controls. Additionally, individuals with high income also had a higher incidence of adverse transitions (HR 1.46, CI 1.34–1.58) compared to controls. Conclusions: Concussion was associated with enhanced risk of adverse transitions between labour market states and lower occurrence of favourable transitions, indicating work disability, potentially due to persistent post-concussive symptoms. Some age groups, individuals with high income, and employees with management experience may be more affected. [ABSTRACT FROM AUTHOR]

There is growing evidence that an individual's personality traits are related to post-concussion symptomatology beyond the acute period after mild traumatic brain injury (mTBI). Few studies, however, have analyzed this impact beyond the personality trait of Neuroticism. We examined the impact of personality traits on post-concussion symptoms (PCS) by measuring the Big Five personality domains and their lower-order aspects in 87 pre-morbidly healthy participants assessed 6–12 weeks post-mTBI (n = 53) or physical trauma (n = 34). As expected, Neuroticism predicted PCS endorsement in both groups. Conscientiousness and Openness/intellect were predictive of lower PCS endorsement, but only in the mTBI group. Withdrawal, one aspect within the Neuroticism domain, independently predicted PCS endorsement in the mTBI group; the remaining Neuroticism aspect, Volatility, did not predict PCS endorsement in either group. These findings suggest that individuals high in Neuroticism are more likely to report PCS following mTBI and that this relationship is driven by susceptibility to depression/anxiety symptoms (Withdrawal aspect) rather than irritability (Volatility aspect). Further, they suggest that the current focus on the relationship between Neuroticism and PCS reporting in individuals with mTBI should be broadened to include other personality domains, such as Conscientiousness and Openness/intellect. [ABSTRACT FROM AUTHOR]

Identifying the principal determinants of life satisfaction following mild TBI (mTBI) may inform efforts to improve subjective well-being in this population. We examined life satisfaction among participants in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study who presented with mTBI (Glasgow Coma Scale [GCS] score = 13-15; n = 1152). An L1-regularization path algorithm was used to select optimal sets of baseline and concurrent symptom measures for prediction of scores on the Satisfaction with Life Scale (SWLS) at 2 weeks and 3, 6, and 12 months post-injury. Multi-variable linear regression models (all n = 744-894) were then fit to evaluate associations between the empirically selected predictors and SWLS scores at each follow-up visit. Results indicated that emotional post-TBI symptoms (all b = -1.27 to -0.77, all p

Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI. Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS. The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up. Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report. [ABSTRACT FROM AUTHOR]

Individuals recovering from mild traumatic brain injury (TBI) represent a heterogenous population that requires distinct treatment approaches. Identification of recovery trajectories improves our ability to understand the natural history of mild TBI recovery and develop targeted interventions. To utilize group-based trajectory modeling (GBTM) to identify distinct patterns of symptom recovery following mild TBI in the first 6 months after mild TBI. This study is comprised of 253 adults who presented to the emergency department with mild TBI and completed assessments for six-months post-injury. Patients were recruited for the prospective observational cohort study, HeadSMART. The primary outcome measure was the Rivermead Postconcussion Symptom Questionnaire. GBTM was used to identify longitudinal trajectories of recovery following mild TBI using Rivermead scores at baseline, one, three, and six months following diagnosis. Findings identified four distinct trajectories of symptom recovery follwing mild TBI including 9% of participants who were categorized with minimal acute symptoms that decreased over time, 45% with mild acute symptoms that decreased over time, 33% with relatively higher acute symptoms that decreased over time, and 13% with relatively higher acute symptoms that increased over time. GBTM identified four distinct trajectories of recovery following mild TBI and GBTM may be useful for research interventions that can alter recovery trajectories. [ABSTRACT FROM AUTHOR]

Background: Individuals who have sustained mild traumatic brain injury (mTBI) with a protracted course of recovery may experience long-lasting somatic, cognitive, and emotional symptoms affecting activities of daily living. There is limited knowledge regarding individuals' lived experiences with treatments and advice provided. Purpose: To explore how individuals with mTBI describe and make sense of their injury, recovery process, and their experiences with various treatment approaches. Methods: Eight participants with mTBI were recruited from the intervention group in an ongoing randomized controlled trial regarding return-to-work. They were interviewed once after treatment delivery using a qualitative hermeneutical approach. Thematic analysis was applied, and findings are discussed in light of a salutogenic theory. Results: Participants expressed uncertainty regarding conflicting advice they received in the early phase of recovery. Three main themes were developed: (1) "Ambiguity and hope"; (2) "Uncertainty concerning activity and rest"; and (3) "To become the person I used to be vs. to become a new version of myself." Conclusion: The findings showed that the participants experienced both uncertainty and hope for further recovery. The recovery process is challenged by the variability of TBI symptoms that affects participation in everyday life, as well as the conflicting advice received by the participants. [ABSTRACT FROM AUTHOR]

Background: In the context of managing persistent post-concussive symptoms (PPCS), existing treatments like pharmacotherapy, cognitive behavioral therapy, and physical rehabilitation show only moderate effectiveness. The emergence of neuromodulation techniques in PPCS management has led to debates regarding optimal stimulation parameters and their overall efficacy. Methods: this scoping review involved a comprehensive search of PubMed and ScienceDirect databases, focusing on controlled studies examining the therapeutic potential of non-invasive brain stimulation (NIBS) techniques in adults with PPCS. Results: Among the 940 abstracts screened, only five studies, encompassing 103 patients (12 to 29 per study), met the inclusion criteria. These studies assessed the efficacy of transcranial direct current stimulation (tDCS), or repetitive transcranial magnetic stimulation (rTMS), applied to specific brain regions (i.e., the left dorsolateral pre-frontal cortex (DLPFC) or left motor cortex (M1)) for addressing cognitive and psychological symptoms, headaches, and general PPCSs. The results indicated improvements in cognitive functions with tDCS. In contrast, reductions in headache intensity and depression scores were observed with rTMS, while no significant findings were noted for general symptoms with rTMS. Conclusion: although these pilot studies suggest promise for rTMS and tDCS in PPCS management, further research with larger-scale investigations and standardized protocols is imperative to enhance treatment outcomes for PPCS patients.

Introduction: Over 70% of traumatic brain injuries (TBI) are classified as mild (mTBI), which present heterogeneously. Associations between pre-injury comorbidities and outcomes are not well-understood, and understanding their status as risk factors may improve mTBI management and prognostication. Methods: mTBI subjects (GCS 13-15) from TRACK-TBI Pilot completing 3- and 6-month functional [Glasgow Outcome Scale-Extended (GOSE)] and post-concussive outcomes [Acute Concussion Evaluation (ACE) physical/cognitive/sleep/emotional subdomains] were extracted. Pre-injury comorbidities >10% incidence were included in regressions for functional disability (GOSE ≤ 6) and post-concussive symptoms by subdomain. Odds ratios (OR) and mean differences (B) were reported. Significance was assessed at p < 0.0083 (Bonferroni correction). Results: In 260 subjects sustaining blunt mTBI, mean age was 44.0-years and 70.4% were male. Baseline comorbidities >10% incidence included psychiatric-30.0%, cardiac (hypertension)-23.8%, cardiac (structural/valvular/ischemic)-20.4%, gastrointestinal-15.8%, pulmonary-15.0%, and headache/migraine-11.5%. At 3- and 6-months separately, 30.8% had GOSE ≤ 6. At 3-months, psychiatric (GOSE ≤ 6: OR = 2.75, 95% CI [1.44-5.27]; ACE-physical: B = 1.06 [0.38-1.73]; ACE-cognitive: B = 0.72 [0.26-1.17]; ACE-sleep: B = 0.46 [0.17-0.75]; ACE-emotional: B = 0.64 [0.25-1.03]), headache/migraine (GOSE ≤ 6: OR = 4.10 [1.67-10.07]; ACE-sleep: B = 0.57 [0.15-1.00]; ACE-emotional: B = 0.92 [0.35-1.49]), and gastrointestinal history (ACE-physical: B = 1.25 [0.41-2.10]) were multivariable predictors of worse outcomes. At 6-months, psychiatric (GOSE ≤ 6: OR = 2.57 [1.38-4.77]; ACE-physical: B = 1.38 [0.68-2.09]; ACE-cognitive: B = 0.74 [0.28-1.20]; ACE-sleep: B = 0.51 [0.20-0.83]; ACE-emotional: B = 0.93 [0.53-1.33]), and headache/migraine history (ACE-physical: B = 1.81 [0.79-2.84]) predicted worse outcomes. Conclusions: Pre-injury psychiatric and pre-injury headache/migraine symptoms are risk factors for worse functional and post-concussive outcomes at 3- and 6-months post-mTBI. mTBI patients presenting to acute care should be evaluated for psychiatric and headache/migraine history, with lower thresholds for providing TBI education/resources, surveillance, and follow-up/referrals. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01565551.

BackgroundConnective tissue disorders such as Ehlers-Danlos Syndrome (EDS) can affect collagen and elastin content and structure, including weakening of tissues and vasculature, thus contributing to multiple systemic manifestations. Prior research has successfully focused on peripheral life-threatening manifestations resulting in increased life expectancy, yet clinical observations have warranted investigation of neurological vulnerability, where little is known. Compromised brain tissues and cerebrovasculature could leave these patients vulnerable to mild traumatic brain injury (TBI), with increased severity and duration of post-concussive symptoms and delayed recovery. Clinical reports in adults indicate that higher severity of symptoms after a mild TBI, such as a concussion, can unmask connective tissues disorders leading toward diagnosis. This clinical case report is an example of a pediatric patient with presumed Ehlers-Danlos syndrome who demonstrates increased vulnerability to mild TBI/concussion.PatientA pediatric female patient presents with unexplained lingering post-concussive symptoms, including trouble sleeping, nausea, frontal headaches, dizziness, visual changes, fatigue, and left-sided weakness more than 6 months post-mild concussion. Patient history of hypermobility, joint derangement, soft tissue mobility, and bruising suggests a potential diagnosis of Ehlers-Danlos syndrome, which may explain symptom severity and length of recovery.DiscussionThis case is the first documented instance of increased vulnerability to TBI in a pediatric patient with presumed Ehlers-Danlos syndrome. It highlights the need for awareness and prevention of injury in this vulnerable patient population, suggests more targeted therapeutic intervention for recovery, and demonstrates the need for preclinical research evaluating the influence of genetic mutations associated with connective tissue disorders on the central nervous system.

Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery. [ABSTRACT FROM AUTHOR]

In the largest sample studied to date, white matter microstructural trajectories and their relation to persistent symptoms were examined after pediatric mild traumatic brain injury (mTBI). This prospective, longitudinal cohort study recruited children aged 8–16.99 years with mTBI or mild orthopedic injury (OI) from five pediatric emergency departments. Children's pre‐injury and 1‐month post‐injury symptom ratings were used to classify mTBI with or without persistent symptoms. Children completed diffusion‐weighted imaging at post‐acute (2–33 days post‐injury) and chronic (3 or 6 months via random assignment) post‐injury assessments. Mean diffusivity (MD) and fractional anisotropy (FA) were derived for 18 white matter tracts in 560 children (362 mTBI/198 OI), 407 with longitudinal data. Superior longitudinal fasciculus FA was higher in mTBI without persistent symptoms relative to OI, d (95% confidence interval) = 0.31 to 0.37 (0.02, 0.68), across time. In younger children, MD of the anterior thalamic radiations was higher in mTBI with persistent symptoms relative to both mTBI without persistent symptoms, 1.43 (0.59, 2.27), and OI, 1.94 (1.07, 2.81). MD of the arcuate fasciculus, −0.58 (−1.04, −0.11), and superior longitudinal fasciculus, −0.49 (−0.90, −0.09) was lower in mTBI without persistent symptoms relative to OI at 6 months post‐injury. White matter microstructural changes suggesting neuroinflammation and axonal swelling occurred chronically and continued 6 months post injury in children with mTBI, especially in younger children with persistent symptoms, relative to OI. White matter microstructure appears more organized in children without persistent symptoms, consistent with their better clinical outcomes. [ABSTRACT FROM AUTHOR]

Older age is associated with worsened outcome after mild traumatic brain injury (mTBI) and a higher risk of developing persistent post-traumatic complaints. However, the effects of mTBI sequelae on brain connectivity at older age and their association with post-traumatic complaints remain understudied. We analyzed multi-echo resting-state functional magnetic resonance imaging data from 25 older adults with mTBI (mean age: 68 years, SD: 5 years) in the subacute phase (mean injury to scan interval: 38 days, SD: 9 days) and 20 age-matched controls. Severity of complaints (e.g. fatigue, dizziness) was assessed using self-reported questionnaires. Group independent component analysis was used to identify intrinsic connectivity networks (ICNs). The effects of group and severity of complaints on ICNs were assessed using spatial maps intensity (SMI) as a measure of within-network connectivity, and (static) functional network connectivity (FNC) as a measure of between-network connectivity. Patients indicated a higher total severity of complaints than controls. Regarding SMI measures, we observed hyperconnectivity in left-mid temporal gyrus (cognitive-language network) and hypoconnectivity in the right-fusiform gyrus (visual-cerebellar network) that were associated with group. Additionally, we found interaction effects for SMI between severity of complaints and group in the visual(-cerebellar) domain. Regarding FNC measures, no significant effects were found. In older adults, changes in cognitive-language and visual(-cerebellar) networks are related to mTBI. Additionally, group-dependent associations between connectivity within visual(-cerebellar) networks and severity of complaints might indicate post-injury (mal)adaptive mechanisms, which could partly explain post-traumatic complaints (such as dizziness and balance disorders) that are common in older adults during the subacute phase. [ABSTRACT FROM AUTHOR]

There are notable gender differences in concussion as well as sleep. Sleep disturbance is a major symptom of post-concussive syndrome. The interplay between sleep disturbance, concussion, and gender has yet to be examined. The objective of this study was to determine whether sleep disturbance plays a role in the known gender differences associated with concussion.Males and females (ages 10-35 years) completed a pre-concussion and post-concussion evaluation. Levels of sleep disturbance were assessed at baseline (N = 1284), after first concussion (N = 432) and after repeated concussions (one or more concussions, N = 296). Sleep disturbance levels were also compared among males and females with headaches, mood changes, and cognitive dysfunction. Analyses included group comparisons and correlations of post-concussive symptoms and cognitive dysfunction, respectively. Data was adjusted for age.Compared to males, females reported higher levels of sleep disturbance after a single concussion; however, levels of sleep disturbance equalized after repeated concussions. Females with higher levels of sleep disturbance had more headaches and more mood changes requiring medical treatment, compared to males. In addition, sleep disturbance was more strongly correlated with cognitive dysfunction in females compared to males.Gender differences in concussion recovery after repeat concussions may be primarily due to a difference in sleep disturbance between the genders. This difference in sleep appears to moderate the levels of other post-concussive symptoms. This indicates that sleep disturbance should be closely monitored and treated in females after a concussion. Further studies are required to determine the underlying reasons for these gender differences.

Recently, there has been a growing interest in the use of cannabis after traumatic brain injury (TBI); however, little is known about the long-term effects of cannabis on milder injuries and post-concussive symptoms. Further, substance use often increases post-TBI and, thus, individuals who chronically use cannabis may unknowingly be exceeding safe or therapeutic doses. The current cross-sectional study explores the prevalence of cannabis use among university students with and without a history of concussion and examines the relationship between concussion and post-concussive symptoms as a function of cannabis use. Eighty-four undergraduates (n = 51 without a prior concussion; n = 33 with a prior concussion) completed a series of questionnaires, capturing their head injury history, current and past substance use, and post-concussive symptomatology. Results indicated that those with a history of concussion were more likely to use cannabis and had higher cannabis use severity scores compared to those without a previous concussion. Further, among cannabis users only, concussion severity demonstrated a significant positive association with post-concussive symptom (e.g., headaches, memory problems) severity (i.e., frequency, intensity, duration). Taken together, the long-term use of cannabis may be detrimental to individuals with a history of concussion, exacerbating, rather than mitigating, post-concussive symptoms. [ABSTRACT FROM AUTHOR]

To describe associations of demographic, military, and health comorbidity variables between mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD) status in a sample of Former and current military personnel. Participants recruited and tested at seven VA sites and one military training facility in the LIMBIC-CENC prospective longitudinal study (PLS), which examines the long-term mental health, neurologic, and cognitive outcomes among previously combat-deployed U.S. Service Members and Veterans (SM/Vs). A total of 1,540 SM/Vs with a history of combat exposure. Data were collected between 1/1/2015 through 3/31/2019. Cross-sectional analysis using data collected at enrollment into the longitudinal study cohort examining demographic, military, and health comorbidity variables across PTSD and mTBI subgroups. PTSD Checklist for DSM-5 (PCL-5), mTBI diagnostic status, Patient Health Questionnaire 9-item (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), AUDIT-C, and other self-reported demographic, military, and health comorbidity variables. Ten years following an index date of mTBI exposure or mid-point of military deployment, combat-exposed SM/Vs with both mTBI history and PTSD had the highest rates of depression symptoms, pain, and sleep apnea risk relative to SM/Vs without both of these conditions. SM/Vs with PTSD, irrespective of mTBI history, had high rates of obesity, sleep problems, and pain. The long-term symptom reporting and health comorbidities among SM/Vs with mTBI history and PTSD suggest that ongoing monitoring and intervention is critical for addressing symptoms and improving quality of life. [ABSTRACT FROM AUTHOR]

A specific variant of neurofeedback therapy (NFT), Live Z -Score Training (LZT), can be configured to not target specific EEG frequencies, networks, or regions of the brain, thereby permitting implicit and flexible modulation of EEG activity. In this exploratory analysis, the relationship between post-LZT changes in EEG activity and self-reported symptom reduction is evaluated in a sample of patients with persistent post-concussive symptoms (PPCS). Penalized regressions were used to identify EEG metrics associated with changes in physical, cognitive, and affective symptoms; the predictive capacity of EEG variables selected by the penalized regressions were subsequently validated using linear regression models. Post-treatment changes in theta/alpha ratio predicted reduction in pain intensity and cognitive symptoms and changes in beta-related power metrics predicted improvements in affective symptoms. No EEG changes were associated with changes in a majority of physical symptoms. These data highlight the potential for NFT to target specific EEG patterns to provide greater treatment precision for PPCS patients. This exploratory analysis is intended to promote the refinement of NFT treatment protocols to improve outcomes for patients with PPCS. [ABSTRACT FROM AUTHOR]

Abstract Objective Motor vehicle collisions generate considerable transmitted forces resulting in traumatic brain injury in children presenting to emergency departments (EDs). To date, no large study has examined post‐concussive symptoms in children sustaining concussions in motor vehicle collisions. This study aimed to compare trends in acute post‐concussive symptom burden in children with concussion following motor vehicle collisions as compared to other injury mechanisms. Methods The study is a secondary analysis of the Predicting Persistent Post‐concussive Problems in Pediatrics study, which prospectively recruited a multicenter cohort of 3029 children 5–17 years of age presenting to the ED with concussion from 2013–2015. Post‐concussive symptom ratings were obtained at pre‐specified time points for 12 weeks post‐injury, using the validated Post‐Concussion Symptom Inventory (PCSI). Symptom severity and recovery trajectories were measured using delta scores on the PCSI (mean post‐injury symptom score minus perceived pre‐injury score). A multivariable, longitudinal model evaluated the adjusted effect of mechanism of injury (motor vehicle collisions vs other mechanisms) on mean symptom scores, compared to perceived pre‐injury reports, and the temporal change in mean scores over during recovery. Results Of 3029 study participants, 56 (1.8%) sustained concussion from motor vehicle collisions. Children sustaining concussion in a motor vehicle collision had lower post‐concussive symptom scores upon ED presentation, measured as differences from their perceived pre‐injury reports, as compared to other injury mechanisms (−0.36 [95% confidence interval (CI) = −0.58, −0.15]). However, the motor vehicle collisions group showed the smallest decline in symptom burden over 1 month following injury (−0.54 [95% CI = −0.81, −0.27]). Conclusions Children sustaining concussions in motor vehicle collisions may have lower initial symptom burdens but slower symptom recovery at 1 month compared to other mechanisms of injury and may represent a distinct population for prognostic counseling in the ED requiring further research.

A specific variant of neurofeedback therapy (NFT), Live Z-Score Training (LZT), can be configured to not target specific EEG frequencies, networks, or regions of the brain, thereby permitting implicit and flexible modulation of EEG activity. In this exploratory analysis, the relationship between post-LZT changes in EEG activity and self-reported symptom reduction is evaluated in a sample of patients with persistent post-concussive symptoms (PPCS). Penalized regressions were used to identify EEG metrics associated with changes in physical, cognitive, and affective symptoms; the predictive capacity of EEG variables selected by the penalized regressions were subsequently validated using linear regression models. Post-treatment changes in theta/alpha ratio predicted reduction in pain intensity and cognitive symptoms and changes in beta-related power metrics predicted improvements in affective symptoms. No EEG changes were associated with changes in a majority of physical symptoms. These data highlight the potential for NFT to target specific EEG patterns to provide greater treatment precision for PPCS patients. This exploratory analysis is intended to promote the refinement of NFT treatment protocols to improve outcomes for patients with PPCS.

The purpose of this study was to examine neurobehavioral symptom reporting in a large sample of military veterans (N = 12,144) who completed the Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and enrolled in the VA's Million Veteran Program (MVP). The CTBIE is a clinician-administered interview that assesses for historical, deployment-related traumatic brain injury (TBI) and evaluates symptoms using the Neurobehavioral Symptom Inventory (NSI). Clinicians completing the CTBIE made clinical determinations about participants' (1) TBI diagnostic status (i.e., CTBIE+ or CTBIE-) and (2) current symptom etiology (i.e., Symptom Resolution, TBI, Behavioral Health, Comorbid TBI + Behavioral Health [Comorbid], or Other). We evaluated the association of TBI diagnostic status and symptom etiology group with neurobehavioral symptoms. Results showed a significant association between TBI diagnostic status and all NSI variables, with CTBIE+ veterans endorsing greater symptoms than CTBIE- veterans. There was also a significant association between symptom etiology group and all NSI variables; specifically, the Comorbid and Behavioral Health groups generally endorsed significantly greater symptoms compared to the other groups. Follow-up analyses showed that relative to the Symptom Resolution group, the Comorbid and Behavioral Health groups had increased odds of severe/very severe cognitive and affective symptoms, whereas the TBI and Other groups did not. Finally, presence of psychiatric symptoms, pain, post-traumatic amnesia, loss of consciousness, and blast exposure significantly predicted Comorbid symptom etiology group membership. Findings from this large epidemiologic MVP study have relevant clinical implications and further highlight the importance of prioritizing integrated behavioral health interventions for this vulnerable population. [ABSTRACT FROM AUTHOR]

To assess which pediatric patients experiencing persistent post-concussive symptoms (PCS) benefit most from multidisciplinary treatment including specialists in Neurology, Neuropsychology, Physical Therapy, and Athletic Training, and to explore the effectiveness of this approach. A retrospective chart review of 56 adolescents 10–20 years old (M = 15.0 ± 2.1) receiving multidisciplinary care for PCS (>30 days) was conducted. Systolic blood pressure and Body Mass Index predicted time to concussion resolution (p <.05), such that higher values were associated with slower resolution. PCS scores significantly decreased between participants' initial and final clinic visits, p <.01, and among the 25 participants for whom pre-intervention PCS scores were available, symptom severity scores significantly declined following multidisciplinary intervention compared to pre-referral values (p <.01). Exploratory analyses reveal that multidisciplinary treatment is a promising approach for reducing symptoms among adolescents with PCS, and that those with greater levels of physical fitness may benefit most. [ABSTRACT FROM AUTHOR]

Self-reported complaints are common after mild traumatic brain injury (mTBI). Particularly in the elderly with mTBI, the pre-injury status might play a relevant role in the recovery process. In most mTBI studies, however, pre-injury complaints are neither analyzed nor are the elderly included. Here, we aimed to identify which individual pre- and post-injury complaints are potential prognostic markers for incomplete recovery (IR) in elderly patients who sustained an mTBI. Since patients report many complaints across several domains that are strongly related, we used an interpretable machine learning (ML) approach to robustly deal with correlated predictors and boost classification performance. Pre- and post-injury levels of 20 individual complaints, as self-reported in the acute phase, were analyzed. We used data from two independent studies separately: UPFRONT study was used for training and validation and ReCONNECT study for independent testing. Functional outcome was assessed with the Glasgow Outcome Scale Extended (GOSE). We dichotomized functional outcome into complete recovery (CR; GOSE = 8) and IR (GOSE ≤ 7). In total 148 elderly with mTBI (median age: 67 years, interquartile range [IQR]: 9 years; UPFRONT: N = 115; ReCONNECT: N = 33) were included in this study. IR was observed in 74 (50%) patients. The classification model (IR vs. CR) achieved a good performance (the area under the receiver operating characteristic curve [ROC-AUC] = 0.80; 95% CI: 0.74–0.86) based on a subset of only 8 out of 40 pre- and post-injury complaints. We identified increased neck pain (p = 0.001) from pre- to post-injury as the strongest predictor of IR, followed by increased irritability (p = 0.011) and increased forgetfulness (p = 0.035) from pre- to post-injury. Our findings indicate that a subset of pre- and post-injury physical, emotional, and cognitive complaints has predictive value for determining long-term functional outcomes in elderly patients with mTBI. Particularly, post-injury neck pain, irritability, and forgetfulness scores were associated with IR and should be assessed early. The application of an ML approach holds promise for application in self-reported questionnaires to predict outcomes after mTBI. [ABSTRACT FROM AUTHOR]

Self-reported complaints are common after mild traumatic brain injury (mTBI). Particularly in the elderly with mTBI, the pre-injury status might play a relevant role in the recovery process. In most mTBI studies, however, pre-injury complaints are neither analyzed nor are the elderly included. Here, we aimed to identify which individual pre- and post-injury complaints are potential prognostic markers for incomplete recovery (IR) in elderly patients who sustained an mTBI. Since patients report many complaints across several domains that are strongly related, we used an interpretable machine learning (ML) approach to robustly deal with correlated predictors and boost classification performance. Pre- and post-injury levels of 20 individual complaints, as self-reported in the acute phase, were analyzed. We used data from two independent studies separately: UPFRONT study was used for training and validation and ReCONNECT study for independent testing. Functional outcome was assessed with the Glasgow Outcome Scale Extended (GOSE). We dichotomized functional outcome into complete recovery (CR; GOSE = 8) and IR (GOSE ≤ 7). In total 148 elderly with mTBI (median age: 67 years, interquartile range [IQR]: 9 years; UPFRONT: N = 115; ReCONNECT: N = 33) were included in this study. IR was observed in 74 (50%) patients. The classification model (IR vs. CR) achieved a good performance (the area under the receiver operating characteristic curve [ROC-AUC] = 0.80; 95% CI: 0.74–0.86) based on a subset of only 8 out of 40 pre- and post-injury complaints. We identified increased neck pain (p = 0.001) from pre- to post-injury as the strongest predictor of IR, followed by increased irritability (p = 0.011) and increased forgetfulness (p = 0.035) from pre- to post-injury. Our findings indicate that a subset of pre- and post-injury physical, emotional, and cognitive complaints has predictive value for determining long-term functional outcomes in elderly patients with mTBI. Particularly, post-injury neck pain, irritability, and forgetfulness scores were associated with IR and should be assessed early. The application of an ML approach holds promise for application in self-reported questionnaires to predict outcomes after mTBI.

Objective: To present pre-injury, injury-related, work-related and post-injury characteristics, and to compare patients with and without traumatic intracranial abnormalities, in a treatment-seeking sample with persistent post-concussion symptoms (PPCS) after mild-to-moderate TBI. Methods: Cross-sectional design in the context of a specialized TBI outpatient clinic. Eligible patients were aged 18–60 years, employed ≥ 50% at time of injury, and sick listed ≥ 50% at inclusion due to PPCS. Data were collected 8–12 weeks after injury through review of medical records, semi-structured interviews, questionnaires, and neuropsychological screening. Results: The study included 116 patients, of whom 60% were women, and predominantly white-collar workers in full-time positions. Ninety-four percent had a mild TBI, and 23% had intracranial abnormalities. The full sample reported high somatic, emotional, and cognitive symptom burden, and decreased health-related quality of life. Patients with normal CT/MRI results reported higher overall symptom burden, while patients with intracranial abnormalities had worse memory function. Conclusion: Injury severity and traumatic intracranial radiological findings should not be the sole ground for planning of rehabilitation service provision in patients with PPCS, as subjective complaints do not necessarily co-vary with these variables. [ABSTRACT FROM AUTHOR]

Mild traumatic brain injury (mTBI or "concussion") is a highly prevalent health condition in children, and those under the age of 6 years have the highest rate of Emergency Department presentation for suspected head injuries. The outcome of mTBI is determined by a range of child (injury, biological, functional) and environmental (socio-economic status, parent, family) factors. The aim of this work is to present evidence supporting the central role of parental and familial factors in pediatric mTBI recovery, and to illustrate ways in which parental factors can especially influence the outcome of early mTBI, defined as injuries sustained by infants, toddlers and preschoolers. The manuscript first presents a topical review of empirical studies providing evidence that family functioning and parental factors such as their mental or affective state, parenting style, and the quality of their interactions with their child, are affected by and determine the course of recovery after pediatric mTBI. Then, a pathway approach and conceptual model are proposed to illustrate probable scenarios associated with how parents detect and react to their child's post-concussive symptoms and changes in behavior after early mTBI. The "Perception, Attribution, and Response after Early Non-inflicted Traumatic Brain Injury" (PARENT) model suggests that parental roles and factors are especially influential in the context of early brain injuries, and that parents' ability to perceive, attribute and respond to the symptoms experienced by their child in a well-adjusted and adaptive manner critically sets the direction and rhythm of the early mTBI recovery process. [ABSTRACT FROM AUTHOR]

Objective  Traumatic brain injury (TBI) is a leading cause of mortality and chronic disability across the globe. This study aimed to understand the effects of cognitive retraining (CR) intervention on neuropsychological functions, symptom reporting, and quality of life in patients with moderate to severe TBI. Materials and Methods  The present single-group intervention study with a pre–post design included 12 patients diagnosed with moderate to severe TBI within 3–24 months post injury. Outcome measures included National Institute of Mental Health and Neuro Sciences (NIMHANS) Neuropsychology Battery, Perceived Stress Scale, Rivermead Post-Concussion Symptom Questionnaire, World Health Organization Quality of Life Scale—Brief, and Visual Analogue Scale. All patients underwent a total of 20 sessions of hospital-based CR, spanning over a period of 2 months. The CR included tasks targeting to enhance processing speed, attention, executive function, learning, and memory. Outcome assessments were conducted at baseline and immediately at post intervention. Statistical Analysis  Mean, standard deviation, frequency, and percentage were used as measures of descriptive statistics. Pre- and post-intervention scores were compared using Wilcoxon signed-rank test. Results  The results showed that at post intervention, significant improvements were found in processing speed, working memory, planning, visuo-spatial construction, visual memory, and verbal encoding. Subjective symptom reporting, perceived stress, and quality of life in psychological domain also improved. Conclusion  CR can be helpful in improving not only cognition but also symptom reporting and quality of life in moderate to severe TBI. [ABSTRACT FROM AUTHOR]

Identifying the principal determinants of life satisfaction following mild TBI (mTBI) may inform efforts to improve subjective well-being in this population. We examined life satisfaction among participants in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study who presented with mTBI (Glasgow Coma Scale [GCS] score = 13–15; n = 1152). An L1-regularization path algorithm was used to select optimal sets of baseline and concurrent symptom measures for prediction of scores on the Satisfaction with Life Scale (SWLS) at 2 weeks and 3, 6, and 12 months post-injury. Multi-variable linear regression models (all n = 744–894) were then fit to evaluate associations between the empirically selected predictors and SWLS scores at each follow-up visit. Results indicated that emotional post-TBI symptoms (all b = −1.27 to −0.77, all p < 0.05), anhedonia (all b = −1.59 to −1.08, all p < 0.01), and pain interference (all b = −1.38 to −0.89, all p < 0.001) contributed to the prediction of lower SWLS scores at all follow-ups. Insomnia predicted lower SWLS scores at 2 weeks, 3 months, and 6 months (all b = −1.11 to −0.83, all ps < 0.01); and negative affect predicted lower SWLS scores at 2 weeks, 3 months, and 12 months (all b = −1.38 to −0.80, all p < 0.005). Other post-TBI symptom domains and baseline socio-demographic, injury-related, and clinical characteristics did not emerge as robust predictors of SWLS scores during the year after mTBI. Efforts to improve satisfaction with life following mTBI may benefit from a focus on the detection and treatment of affective symptoms, pain, and insomnia. The results reinforce the need for tailoring of evidence-based treatments for these conditions to maximize efficacy in patients with mTBI. [ABSTRACT FROM AUTHOR]

Post-concussive symptoms are frequently reported by individuals who sustain mild traumatic brain injuries (mTBIs) and subconcussive head impacts, even when evidence of intracranial pathology is lacking. Current strategies used to evaluate head injuries, which primarily rely on self-report, have a limited ability to predict the incidence, severity, and duration of post-concussive symptoms that will develop in an individual patient. In addition, these self-report measures have little association with the underlying mechanisms of pathology that may contribute to persisting symptoms, impeding advancement in precision treatment for TBI. Emerging evidence suggests that biofluid, imaging, physiological, and functional biomarkers associated with mTBI and subconcussive head impacts may address these shortcomings by providing more objective measures of injury severity and underlying pathology. Interest in the use of biomarker data has rapidly accelerated, which is reflected by the recent efforts of organizations such as the National Institute of Neurological Disorders and Stroke and the National Academies of Sciences, Engineering, and Medicine to prioritize the collection of biomarker data during TBI characterization in acute-care settings. Thus, this review aims to describe recent progress in the identification and development of biomarkers of mTBI and subconcussive head impacts and to discuss important considerations for the implementation of these biomarkers in clinical practice.

Protective factors, including psychological resilience, cognitive reserve, and brain reserve, may be positively associated with recovery after pediatric mild traumatic brain injury (mTBI) but are yet to be studied concurrently. We sought to examine these factors as moderators of post-concussive symptoms (PCS) in pediatric mTBI compared with mild orthopedic injury (OI). Participants included 967 children (633 mTBI, 334 OI) aged 8-16.99 years, recruited from 5 Canadian pediatric emergency departments as part of a prospective longitudinal cohort study. At 10 days post-injury, psychological resilience was measured using the Connor-Davidson Resilience Scale and brain reserve was measured using total brain volume derived from structural magnetic resonance imaging. Cognitive reserve was measured at 3 months post-injury using IQ scores from the Wechsler Abbreviated Scale of Intelligence-Second Edition. Cognitive and somatic PCS were measured using child and parent ratings on the Health and Behavior Inventory, completed weekly for 3 months and biweekly to 6 months. Analyses involved generalized least-squares regression models using restricted cubic splines. Covariates included age at injury, sex, racialized identity, material and social deprivation, pre-injury migraine and concussion history, and retrospective pre-injury PCS. Psychological resilience moderated group differences in parent-reported PCS. At 30 days post-injury, estimated group differences in parent-reported cognitive and somatic PCS (mTBI > OI) were larger at higher (75th percentile) resilience scores ( Est = 2.25 [0.87, 3.64] and Est = 2.38 [1.76, 3.00], respectively) than at lower (25th percentile) resilience scores ( Est = 1.44 [0.01, 2.86] and Est = 2.08 [1.45, 2.71], respectively). Resilience did not moderate group differences in child-reported PCS but was negatively associated with child-reported PCS in both groups ( p s ≤ 0.001). Brain reserve (i.e., total brain volume [TBV]) also moderated group differences, but only for parent-reported somatic PCS ( p = 0.018). Group difference (mTBI > OI) at 30 days was larger at smaller (25th percentile) TBV ( Est = 2.78 [2.17, 3.38]) than at larger (75th percentile) TBV ( Est = 1.95 [1.31, 2.59]). TBV was not associated with parent-reported cognitive PCS or child-reported PCS. IQ did not moderate PCS in either group but had a significant non-linear association in both groups with child-reported somatic PCS ( p = 0.018) and parent-reported PCS ( p < 0.001), with higher PCS scores at both lower and higher IQs. These findings suggest that higher resilience predicts fewer PCS, but less strongly after mTBI than OI; greater brain reserve may reduce the effect of mTBI on somatic PCS; and cognitive reserve has an unexpected curvilinear association with PCS across injury types. The results highlight the importance of protective factors as predictors of recovery and potential targets for intervention following pediatric mTBI.

The majority of traumatic brain injuries (TBIs) are categorized as mild, according to a baseline Glasgow Coma Scale (GCS) score of 13–15. Prognostic models that were developed to predict functional outcome and persistent post-concussive symptoms (PPCS) after mild TBI have rarely been externally validated. We aimed to externally validate models predicting 3–12-month Glasgow Outcome Scale Extended (GOSE) or PPCS in adults with mild TBI. We analyzed data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) project, which included 2862 adults with mild TBI, with 6-month GOSE available for 2374 and Rivermead Post-Concussion Symptoms Questionnaire (RPQ) results available for 1605 participants. Model performance was evaluated based on calibration (graphically and characterized by slope and intercept) and discrimination (C-index). We validated five published models for 6-month GOSE and three for 6-month PPCS scores. The models used different cutoffs for outcome and some included symptoms measured 2 weeks post-injury. Discriminative ability varied substantially (C-index between 0.58 and 0.79). The models developed in the Corticosteroid Randomisation After Significant Head Injury (CRASH) trial for prediction of GOSE <5 discriminated best (C-index 0.78 and 0.79), but were poorly calibrated. The best performing models for PPCS included 2-week symptoms (C-index 0.75 and 0.76). In conclusion, none of the prognostic models for early prediction of GOSE and PPCS has both good calibration and discrimination in persons with mild TBI. In future studies, prognostic models should be tailored to the population with mild TBI, predicting relevant end-points based on readily available predictors. [ABSTRACT FROM AUTHOR]

The purpose of this study was to examine rates of and relationships between "post-concussive" symptom endorsement and symptom attribution in Veterans with a history of mild traumatic brain injury (mTBI). This cross-sectional, exploratory study included 48 combat-exposed Iraq/Afghanistan Veterans with remote history of mTBI. All Veterans completed clinical interviews and self-report questionnaires assessing sociodemographic factors, injury and combat-related variables, psychiatric distress, self-efficacy, and coping style. To assess symptom endorsement and symptom attribution, a modified version of the Neurobehavioral Symptom Inventory was administered. Results showed that the most commonly endorsed "post-concussive" symptoms were several non-specific symptoms, while the symptoms most frequently attributed to mTBI included forgetfulness, poor concentration, and headaches. Furthermore, although there were some overlapping correlates of both symptom endorsement and symptom attribution, unique variables were associated with each domain. Specifically, symptom endorsement was uniquely associated with measures of psychiatric distress, while symptom attribution was uniquely associated with having a history of loss of consciousness and a greater degree of combat exposure. Taken together, results suggest that endorsement of symptoms may be significantly impacted by the presence of mental health comorbidities, but that perceptions or beliefs as to why symptoms are occurring are related more to mTBI and combat-related characteristics. Findings offer potential avenues for therapeutic intervention, emphasize the importance of psychoeducation, and highlight the need to consider using alternate terminology for these symptoms that promotes recovery and minimizes misattribution of symptoms. [ABSTRACT FROM AUTHOR]

To elucidate the predictive factors for persistent post-concussion symptoms at 1 and 3 months following minor traumatic brain injuries (mTBIs) in patients with no psychiatric history. This was an observational study in an academic trauma centre including adult patients with a history of mTBI and no psychiatric history. Exclusion criteria were missing the follow-up phone calls, radiologic abnormalities, simultaneous injuries and refusal to participate. Outcomes were post-concussion syndrome according to the international classification of diseases (ICD)-10 (ICD-PCS) and persistence of more than one mTBI related symptoms at 1 and 3 months post-injury. From 364 enrolled patients, 16 (4.4%) developed ICD-PCS, whereas 28 (7.6%) and 8(2.1%) reported more than one symptom at one and three months, respectively. Multivariable analysis showed associations between ICD-PCS with more than one initial symptom in the emergency department (ED) and the non-motor vehicle collision (non-MVC) impact mechanism with area under curve of 0.77. The former variable was associated with the persistence of more than one post-concussion symptom at one and three months. More than one symptom in the ED and the mechanism of injury not related to MVCs (sports, violence or fall injuries) may predict symptom persistence. Early treatment and follow-up strategies may be beneficial for vulnerable patients. [ABSTRACT FROM AUTHOR]

Children do not always receive adequate medical attention following a mild traumatic brain injury (mTBI), despite the necessity of this treatment. Adult mTBI knowledge may be one factor that affects if a child receives medical attention, but little is known about association between mTBI knowledge and help-seeking behaviour. Participants were 212 females and 58 males, including 84 parents, with a mean age of 35.57 years (standard deviation = 10.96). A questionnaire evaluated participants' understanding of mTBI and vignettes to evaluate behavioural intentions regarding help-seeking behaviour after an mTBI. Only 40.0% of participants were able to recall an adequate number of mTBI symptoms (5+). Surprisingly, mTBI history was not associated with better mTBI knowledge, t (df, 268) = 1.29, p =.20. Similarly, knowing a close friend or family member with mTBI was not associated with higher mTBI knowledge, t (df = 268) =.81, p =.4. Further, neither mTBI symptom knowledge nor vignette child age (young = 5 years, older = 15 years) significantly predicted participants' cited intentions to perform help-seeking behaviour. Consistent with the existing research, the current study demonstrates a continued lack of mTBI knowledge in the general population. However, this may not be a factor that influences an adult's decision to take a child to hospital following mTBI. Future research should investigate the association between help-seeking intentions and actual behaviour in relation to paediatric mTBI. [ABSTRACT FROM AUTHOR]

Introduction: Over 70% of traumatic brain injuries (TBI) are classified as mild (mTBI), which present heterogeneously. Associations between pre-injury comorbidities and outcomes are not well-understood, and understanding their status as risk factors may improve mTBI management and prognostication.Methods: mTBI subjects (GCS 13–15) from TRACK-TBI Pilot completing 3- and 6-month functional [Glasgow Outcome Scale-Extended (GOSE)] and post-concussive outcomes [Acute Concussion Evaluation (ACE) physical/cognitive/sleep/emotional subdomains] were extracted. Pre-injury comorbidities >10% incidence were included in regressions for functional disability (GOSE ≤ 6) and post-concussive symptoms by subdomain. Odds ratios (OR) and mean differences (B) were reported. Significance was assessed at p < 0.0083 (Bonferroni correction).Results: In 260 subjects sustaining blunt mTBI, mean age was 44.0-years and 70.4% were male. Baseline comorbidities >10% incidence included psychiatric-30.0%, cardiac (hypertension)-23.8%, cardiac (structural/valvular/ischemic)-20.4%, gastrointestinal-15.8%, pulmonary-15.0%, and headache/migraine-11.5%. At 3- and 6-months separately, 30.8% had GOSE ≤ 6. At 3-months, psychiatric (GOSE ≤ 6: OR = 2.75, 95% CI [1.44–5.27]; ACE-physical: B = 1.06 [0.38–1.73]; ACE-cognitive: B = 0.72 [0.26–1.17]; ACE-sleep: B = 0.46 [0.17–0.75]; ACE-emotional: B = 0.64 [0.25–1.03]), headache/migraine (GOSE ≤ 6: OR = 4.10 [1.67–10.07]; ACE-sleep: B = 0.57 [0.15–1.00]; ACE-emotional: B = 0.92 [0.35–1.49]), and gastrointestinal history (ACE-physical: B = 1.25 [0.41–2.10]) were multivariable predictors of worse outcomes. At 6-months, psychiatric (GOSE ≤ 6: OR = 2.57 [1.38–4.77]; ACE-physical: B = 1.38 [0.68–2.09]; ACE-cognitive: B = 0.74 [0.28–1.20]; ACE-sleep: B = 0.51 [0.20–0.83]; ACE-emotional: B = 0.93 [0.53–1.33]), and headache/migraine history (ACE-physical: B = 1.81 [0.79–2.84]) predicted worse outcomes.Conclusions: Pre-injury psychiatric and pre-injury headache/migraine symptoms are risk factors for worse functional and post-concussive outcomes at 3- and 6-months post-mTBI. mTBI patients presenting to acute care should be evaluated for psychiatric and headache/migraine history, with lower thresholds for providing TBI education/resources, surveillance, and follow-up/referrals.Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT01565551.

Objective: Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. Method: Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). Results: Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. Conclusion: Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment. [ABSTRACT FROM AUTHOR]

Objective: Concussion in children and adolescents is a prevalent problem with implications for subsequent physical, cognitive, behavioral, and psychological functioning, as well as quality of life. While these consequences warrant attention, most concussed children recover well. This study aimed to determine what pre-injury, demographic, and injury-related factors are associated with optimal outcome ("wellness") after pediatric concussion. Method: A total of 311 children 6–18 years of age with concussion participated in a longitudinal, prospective cohort study. Pre-morbid conditions and acute injury variables, including post-concussive symptoms (PCS) and cognitive screening (Standardized Assessment of Concussion, SAC), were collected in the emergency department, and a neuropsychological assessment was performed at 4 and 12 weeks post-injury. Wellness, defined by the absence of PCS and cognitive inefficiency and the presence of good quality of life, was the main outcome. Stepwise logistic regression was performed using 19 predictor variables. Results: 41.5% and 52.2% of participants were classified as being well at 4 and 12 weeks post-injury, respectively. The final model indicated that children who were younger, who sustained sports/recreational injuries (vs. other types), who did not have a history of developmental problems, and who had better acute working memory (SAC concentration score) were significantly more likely to be well. Conclusions: Determining the variables associated with wellness after pediatric concussion has the potential to clarify which children are likely to show optimal recovery. Future work focusing on wellness and concussion should include appropriate control groups and document more extensively pre-injury and injury-related factors that could additionally contribute to wellness. (JINS , 2019, 25 , 375–389) [ABSTRACT FROM AUTHOR]

Objectives: Examine the mediating effects of anxiety and depressive symptoms on the relationship between psychological resilience and post-concussive symptoms (PCS) in children with poor recovery following concussion. Participants and Methods: Adolescents (N =93), ages 13 to 18 years, were assessed at a neuropsychology screening clinic at a children's hospital. They sustained concussions more than 1 month before the clinic visit (median time since injury=5.1 months; range=42–473 days) and were seen on the basis of poor recovery (i.e., presence of persistent PCS and complaints of cognitive problems). Self-reported psychological resilience was measured using the 10-item version of the Connor-Davidson Resilience Scale; self- and parent-reported anxiety and depressive symptoms were measured using the Behaviour Assessment System for Children – Second Edition; and self- and parent-reported PCS were measured using the Post-Concussion Symptom Inventory. All variables were measured concurrently. Regression-based mediation analyses were conducted to examine anxiety and depressive symptoms as mediators of the relationship between psychological resilience and PCS. Results: Psychological resilience significantly predicted self-reported PCS. Self-reported anxiety and depressive symptoms significantly mediated the relationship between resilience and self-reported PCS, and parent-reported child depressive symptoms significantly mediated the relationship between resilience and self- and parent-reported PCS. Conclusions: Psychological resilience plays an important role in recovery from concussion, and this relationship may be mediated by anxiety and depressive symptoms. These results help shed light on the mechanisms of the role of psychological resilience in predicting PCS in children with prolonged symptom recovery. (JINS , 2019, 25 , 346–354) [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility of recruitment procedures and delivery of a Norwegian adaptation of a manualized cognitive intervention to a civilian sample with traumatic brain injury (TBI). Materials and methods: Six individuals received a 10-week group-based intervention (Compensatory Cognitive Training, CCT) targeting post-concussive symptom management and cognitive symptoms. Participant engagement (i.e. attendance, level of participation, ability to learn and apply strategies, and homework completion) and satisfaction were assessed by the Therapist Checklist and CCT Feedback Form. Results: All participants had a diagnosis of concussion, were enrolled on average 4 months post-injury, and were sick-listed at a range of 70–100% at the time of inclusion. Attendance across CCT sessions was 97%. Eight out of nine topics in the CCT-intervention received a rating above 3.5 on a 5-point scale (i.e. towards very helpful). The items that received the highest mean ratings were information about TBI and post-concussive symptoms, and strategies targeting fatigue, prospective memory, and memory and learning. All participants were rated as participating fully (3/6) or moderately (3/6), and most participants (5/6) attempted to apply the trained skills to real-life situations. Conclusions: The results support the feasibility of a Norwegian adaptation of the intervention for a civilian sample with TBI.

Mild traumatic brain injury (mTBI) remains the most commonly reported head injury in the United States, and is associated with a wide range of post-concussive symptoms including physical, cognitive and affective impairments. Elevated aggression has been documented in mTBI; however, the neural mechanisms associated with aggression at the chronic stage of recovery remain poorly understood. In the present study, we investigated the association between white matter integrity and aggression in mTBI using diffusion tensor imaging (DTI). Twenty-six age-matched adults participated in the study, including 16 healthy controls (HCs) and 10 individuals in the chronic stage of recovery (either 6-months or 12 months post-mTBI). Psychological measures of aggression included the Buss-Perry Aggression Questionnaire and the Personality Assessment Inventory (PAI). Axonal pathways implicated in affective processing were studied, including the corpus callosum, anterior thalamic radiation, cingulum and uncinate fasciculus, and measures of white matter integrity included fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD). We found that adults with mTBI in the chronic stage of recovery had higher levels aggression. Individuals with mTBI also had greater RD in the corpus callosum compared to HCs, indicating reduced fiber integrity. Furthermore, we observed a significant association between reduced white matter integrity in the corpus callosum and greater aggression. Our findings provide additional evidence for underlying neuroanatomical mechanisms of aggression, although future research will be necessary to characterize the specific relationship between aggression and the white matter pathways we identified.

Aim: The aim of the present study is to evaluate diffusion tensor tractography (DTT) as a tool for detecting diffuse axonal injury in patients of acute, mild, and moderate traumatic brain injury (TBI), using two diffusion variables: Fractional anisotropy (FA) and mean diffusivity (MD). The correlation of these indices with the severity of post-concussive symptoms was also assessed. Materials and Methods: Nineteen patients with acute, mild, or moderate TBI and twelve age- and sex-matched healthy controls were recruited. Following Magnetic Resonance Imaging (MRI) on a 3.0-T scanner, DTT was performed using the 'fiber assignment by continuous tracking' (FACT) algorithm for fiber reconstruction. Appropriate statistical tools were used to see the difference in FA and MD values between the control and patient groups. In the latter group, the severity of post-concussive symptoms was assessed six months following trauma, using the Rivermead Postconcussion Symptoms Questionnaire (RPSQ). Results: The patients displayed significant reduction in FA compared to the controls (P < 0.05) in several tracts, notably the corpus callosum, fornix, bilateral uncinate fasciculus, and bilateral superior thalamic radiations. Changes in MD were statistically significant in the left uncinate, inferior longitudinal fasciculus, and left posterior thalamic radiation. A strong correlation between these indices and the RPSQ scores was observed in several white matter tracts. Conclusion: Diffusion tensor imaging (DTI)-based quantitative analysis in acute, mild, and moderate TBI can identify axonal injury neuropathology, over and above that visualized on conventional MRI scans. Furthermore, the significant correlation observed between FA and MD indices and the severity of post-concussive symptoms could make it a useful predictor of the long-term outcome.